Cases/Maternity and Reproductive Health

Woman At Ten Weeks Unable to Keep Fluids Down — Free SCA Practice Case

Woman at ten weeks unable to keep fluids down

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Aoife Lennon

Age

27 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I'm being sick all the time. The tablets I was given last week aren't helping."

Medical Records

●PMH: Nil significant. Second pregnancy, 10 weeks by dates, planned; not yet booked, no scan. Normal delivery 20 months ago.
●Medications: Cyclizine 50 mg three times a day, started 8 days ago. NKDA.
●Weight: 68 kg (4 months ago).
●Social: Part time florist's assistant. Lives with partner and son.

Recent Notes

●GP phone call, 8 days ago: Vomiting five times daily for a week, keeping fluids down, passing urine normally. No pain or bleeding.

Patient Script

For the friend playing the patient role

Character Overview: You are Aoife Lennon, a 27 year old florist's assistant who works Wednesday to Friday. You grew up in Cork and live with your partner Andre, a kitchen fitter, and your 20 month old son Fionn. You are 10 weeks pregnant with your second baby, which was planned. With Fionn you were queasy for a few weeks, so you assumed this would be the same. This time you have been sick for nearly four weeks, it has got steadily worse, and for the past week you have been sick more than ten times a day. Today is Tuesday, not a work day, so Fionn is in the next room with the television on. You sound washed out and quiet, your voice wobbles, and you apologise a lot. You speak slowly because talking sets off the nausea, but you answer every question directly. You never use a medical name for what you have. You are not afraid of medicines.

Opening Sentence: "Hi, doctor. Sorry to ring again. I'm ten weeks pregnant and I can't keep anything down. I've been sick more than ten times a day for the last week now, and the tablets I got last week aren't doing anything. I know everyone gets morning sickness, but I can't carry on like this."

History if Asked (Data Gathering Phase)

●How it started: "I felt queasy from about five weeks. The being sick started at about six and a half weeks and crept up. Last week it went from about five times a day to more than ten, and it's been like that every day since."
●The last day (if asked about nausea, vomiting or retching): "The nausea is all day, it never really goes, definitely more than six hours. I've lost count of the sick, ten or twelve times at least since yesterday, and it woke me in the early hours this morning. When there's nothing left I just retch, five or six times a day. Only water and bitter yellow stuff now, no blood."
●The tablets (if asked about medicines or whether they are helping): "Cyclizine, 50 milligrams three times a day, from the surgery last week. I've taken every one. Most come back up within about ten minutes. Maybe one in three stays down, and even those haven't made any difference."
●Fluids and food (if asked): "Tiny sips of water or flat lemonade, and they come back after a few minutes. About a cup and a half has stayed down since yesterday. A couple of plain crackers yesterday lunchtime came back up an hour later. Nothing since."
●Passing urine (if asked): "I went at about seven this morning. Hardly anything, and it was dark orange. I haven't been since. That's about eight hours, isn't it? I hadn't really thought about it."
●How she feels in herself (if asked about dizziness, mouth, heart or head): "My mouth and lips are really dry. I get dizzy when I stand, I had to hold the worktop earlier, and my heart thumps when I walk to the bathroom. I've had a dull headache since this morning, nothing sudden or terrible."
●Weight (if asked): "I weighed myself this morning. I was sixty eight kilos before I got pregnant, that's what they had at the surgery, and I'm sixty two and a half today."

Ideas, Concerns, Expectations

Gating note: Aoife does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for from today.

●Ideas: She thinks this is an extra bad dose of the sickness everyone gets, that her tablets are not strong enough, and that she is not coping as well as other women. "I thought it'd be like it was with Fionn, so I suppose I'm just not managing it as well as other people do."
●Concerns: She is frightened for the baby because she is not eating or drinking. "Am I starving the baby? I've barely kept anything down for days." She dreads being sent into hospital because Fionn has never spent a night away from her, and she feels foolish for ringing about something everyone calls normal.
●Expectations: She hoped for stronger tablets, or an injection at the surgery, and then to go home to Fionn. "I was hoping you could give me something stronger, or an injection here, and I could go home and sleep."

If Asked: Medical History and Medications

Gating note: Aoife answers each of these plainly when the doctor asks about it.

●Health and family: "Nothing really. I've never been in hospital apart from having Fionn. No diabetes, kidney or thyroid problems, nothing with my stomach. My sister Roisin was on a drip twice with her pregnancies, she was sick the whole way through. My mum said she was sick with me as well."
●First pregnancy: "A normal delivery at 39 weeks. I was queasy for a few weeks, nothing like this."
●Medicines and allergies: "Just the cyclizine. I haven't taken any vitamins this week, I can't face the smell of the tub. No allergies."
●This pregnancy: "My periods come every 28 days or so and my last one started about ten weeks ago. I did a test at about five weeks. I filled in the midwives' form last week. I haven't had a scan. No bleeding, no discharge, no tummy pain apart from sore muscles from the retching."
●Smoking and alcohol: "I don't smoke and I haven't had a drink since I found out."

Social History and Lifestyle Impact

●Work and home: Off sick from the flower shop since last Friday.
●Support: "Andre's on a kitchen job about 25 minutes away, he left at seven and he's got the van. If I rang him he'd come, his boss is fine about emergencies." His mum Maria lives fifteen minutes away, works at the council offices and finishes at five. Sandra next door has had Fionn for an hour or two before.
●Driving: "I wouldn't drive like this, I'm too dizzy."
●Mood (if asked how she is coping): "I've been crying most days. I feel like a useless mum, Fionn's had the telly on all day because I can't do anything with him. I'd never hurt myself or anything like that. I'm just exhausted and I want it to stop."

If Asked: Associated Symptoms

Gating note: Answers are brief and natural. The following are all negative: fever or shivering, pain or burning passing urine, diarrhoea (she is constipated, no bowels opened for about three days), sickness bug contacts at home, vomiting blood or black stools, severe or sudden headache, confusion, double vision, unsteadiness or trouble walking, yellow skin or eyes, calf pain, chest pain or breathlessness, shaking or sweating, twins in the family. She has heartburn after being sick.

Responses to Management (The Negotiation Phase)

●
If the doctor says she needs to be seen in hospital or an assessment unit today:
- ●Reaction: Upset and resistant. "Today? But Fionn... can't you give me something stronger, or an injection here?" She agrees once told she is dried out, that she needs fluids through a drip which the practice cannot give, and that tablets will not help while she vomits them up. "A drip. Right. I didn't realise it was that bad." She is relieved if the doctor will phone ahead and says: "Do I wait by the phone? When do I need to be there, and where do I go?"
●
If the doctor suggests another swallowed tablet, ginger, small snacks, or says it is just pregnancy sickness that eases by 12 weeks:
- ●Reaction: Flat, then tearful. "I've tried all of that. Little and often, ice lollies, even the wristbands Andre bought me. I can't keep a sip of water down. I can't last till twelve weeks." She is open to a tablet that dissolves under the lip, or a drip.
●
If the doctor asks what is worrying her, asks about the baby, or about her mood:
- ●Reaction: "Is the baby going to be all right? Am I starving it?" She is steadier if the doctor is honest and unsettled by a bare promise. "You can't promise that, though, can you?" If the doctor says it is not her fault or that this is an illness: "Thank you. I just needed someone to say it isn't me being weak." If asked to check her own pulse or tongue, she declines and asks to be properly examined.
●
If the doctor asks who could look after Fionn, or how she gets to hospital:
- ●Reaction: She thinks aloud. "Andre could come and take me. Maria could have Fionn from five. Sandra next door could have him till then, I think. I'd have to ring her." She settles on a plan if the doctor helps join the pieces up, and stays stuck if only told to sort it out. If told to go to A and E alone: "A and E with a toddler, for hours?" If an ambulance is suggested she is alarmed, then accepts it because she is dizzy, though she prefers Andre.
●
If the doctor says she might be kept in, or explains what will happen at the hospital:
- ●Reaction: Worried. "Overnight? Fionn's never been away from me at night." If the doctor says it depends on how she gets on and she may be home the same day after a few hours on a drip: "Okay. At least I can tell Andre to pack a bag just in case." If promised she will be home tonight: "Oh, good. So I'll be back for Fionn's bedtime." On hearing about a drip, injections, blood tests and a scan: "A scan? I haven't had one yet. That would be nice."
●
If the doctor gives safety netting, a sick note or follow up:
- ●Reaction: To "come back if it gets worse": "Worse than this? How would I know? What should make me ring an ambulance rather than wait?" She is grateful for a fit note: "Yes, please. Work will want one." Asked about follow up: "So you'll ring me? Or do I ring you?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Nausea and vomiting in pregnancy usually begins at 4 to 7 weeks, peaks at 9 to 16 weeks and settles by 16 to 20 weeks. Hyperemesis gravidarum is the severe end: vomiting that stops a woman eating, drinking and functioning, with dehydration, affecting about 0.3% to 3.6% of pregnancies (RCOG Green top guideline 69, 2024).
●The skill is recognising that Aoife has stopped being an "advise and prescribe" problem. She cannot keep tablets or fluids down, has passed no urine for about 8 hours and has lost about 8% of her weight. She needs intravenous fluids and non oral treatment today, which cannot be given or properly assessed over video.
●Model plan: same day in person assessment arranged by a phone call, a safe journey, a childcare plan built with her, honest answers about staying in, a named safety net and follow up. Acceptable alternatives: a direct call to an early pregnancy, maternity or gynaecology assessment unit, an ambulatory day care or IV fluid service, the on call obstetric team, A and E after a phone call where there is no assessment route, or a review at the practice today with onward same day referral. Day case or admission is the receiving unit's decision.

Scoring Severity and the Referral Criteria

●The PUQE score (Pregnancy Unique Quantification of Emesis) scores hours of nausea, number of vomits and number of retches in the last 24 hours from 1 to 5 each. Mild is 6 or less, moderate 7 to 12 and severe 13 to 15. Aoife scores 5, 5 and 4, a total of 14.
●NICE CKS (May 2026) advises considering referral or admission for persistent moderate to severe symptoms with any of: inability to tolerate oral antiemetics or fluids, clinical dehydration, weight loss over 5%, suspected hyperemesis despite oral antiemetics, a suspected complication, mental health concerns or a PUQE score of 13 or more. Aoife meets most of them.
●Weight loss: 68 kg before pregnancy and 62.5 kg now is 5.5 kg, about 8%. Five per cent of 68 kg is 3.4 kg.
●The RCOG advises that ketonuria is not an indicator of dehydration, so a ketone dipstick does not decide anything. Dehydration is judged from the history, examination and blood tests. As summarised by CKS, outpatient care may be possible when PUQE is below 13, so local pathways differ and the unit chooses day case or admission.

What Cannot Be Done Over Video

●A woman with severe symptoms needs temperature, blood pressure, pulse, postural blood pressure, mucous membranes, saturations, weight, abdominal examination and a check for confusion, nystagmus or ataxia that could signal Wernicke's encephalopathy (damage from thiamine deficiency).
●The tested behaviour is not self examination. It is recognising that the history already points to dehydration and arranging in person assessment today.
●Investigations include urine dipstick, full blood count, urea and electrolytes, glucose and a pelvic ultrasound to look for a multiple or molar pregnancy. Aoife has had no scan, which is another reason for an early pregnancy or maternity unit.

Alternative Causes and Red Flags

●Vomiting that starts after 11 weeks usually has another cause. Hers began at about 6 and a half weeks.
●Exclude urinary tract infection, gastroenteritis, gastritis, pancreatitis, cholecystitis, appendicitis, hepatitis, thyrotoxicosis, diabetic ketoacidosis, migraine or other neurological causes, drug causes and, later in pregnancy, acute fatty liver and pre eclampsia. Ask about abdominal pain, bleeding, urinary symptoms, fever, diarrhoea, vomited blood, severe headache and neurological symptoms.
●Risk factors for severe disease include a multiple or molar pregnancy, previous hyperemesis and a family history. Her sister needed a drip in both pregnancies.
●Diabetes or kidney disease makes ketoacidosis or acute kidney injury more likely when vomiting.

Drug Treatment, Step by Step

●First line (CKS, BNF, RCOG): cyclizine 50 mg up to three times a day, promethazine, prochlorperazine 5 to 10 mg up to three times a day orally or 3 to 6 mg twice a day buccally, chlorpromazine, or doxylamine with pyridoxine, the only licensed product. Reassess at 24 to 72 hours, then weekly.
●Second line: metoclopramide up to 8 hourly for no more than 5 days (extrapyramidal effects), domperidone for no more than 7 days, or ondansetron for no more than 5 days. First trimester ondansetron carries a small increased risk of cleft lip or palate (MHRA, January 2020), about 11 to 14 per 10,000 births. The RCOG says its use should not be discouraged when first line drugs fail.
●Third line: oral prednisolone 40 to 50 mg daily for failure of standard treatment, tapered to the lowest effective dose, with specialist advice if it is not effective. Combining classes is encouraged.
●A woman vomiting tablets back needs a non oral route: injection or infusion in hospital, or buccal prochlorperazine in the community. Reduce treatment gradually at about 12 to 16 weeks, because stopping early often leads to relapse.
●NICE NG201 suggests ginger for mild to moderate symptoms. The RCOG, via CKS, advises against suggesting it for severe symptoms because it delays effective treatment.

What Ambulatory Care and Admission Involve

●Observations, weight, urine and blood tests, and an ultrasound scan if none has been done.
●Intravenous fluids with electrolyte replacement (RCOG: normal saline with potassium chloride, guided by daily electrolytes), antiemetics by injection or infusion, and thiamine for all women admitted with vomiting or very poor intake, ideally before any dextrose.
●A venous thromboembolism risk assessment, often with low molecular weight heparin if admitted.
●Severe symptoms later in pregnancy merit serial growth scans (NG201), because hyperemesis is linked with low birth weight and preterm delivery.

Mood, Complications and Practical Support

●Complications include weight loss, electrolyte disturbance, acute kidney injury, vitamin deficiency, reflux, thrombosis and psychological harm. Treat reflux with an H2 blocker or proton pump inhibitor.
●Ask about mood. Many women feel guilty, isolated and unable to care for older children. Reassure that this is an illness. CKS lists mental health concerns as a reason to consider admission.
●Pregnancy Sickness Support and the RCOG leaflet are reliable sources. A fit note helps with work. Early treatment in a future pregnancy may reduce severity.

Safety Netting and Follow Up

●Call 999 for fainting, confusion or marked drowsiness, double vision or unsteadiness, chest pain or breathlessness, a swollen painful calf, severe abdominal pain, heavy vaginal bleeding or vomiting blood, and ring the practice or unit if she is not seen at the agreed time.
●A dizzy, dehydrated woman should not drive. Use an ambulance if there is no safe transport or she faints.
●Arrange contact the next day or on discharge, weekly review while symptoms continue, a plan if the first drug is not enough, and inform the midwife and maternity team.

Common Mistakes in This Station

●Treating a woman with no urine for 8 hours as a moderate case, changing the tablet and reviewing in 24 to 72 hours.
●Swapping or increasing swallowed tablets when she is vomiting most doses back.
●Leaving her to find her own way to hospital without a phone call, or letting her drive while dizzy.
●Relying on a ketone dipstick, ginger or small meals as the main plan.
●Promising she will be home tonight, or that she will certainly be admitted.
●Saying it is "just morning sickness" that will end by 12 weeks, which she hears as dismissal.
●Not asking about urine, weight loss, mood or who can mind the toddler.
●Vague safety netting such as "come back if it gets worse".

Mapped to the RCGP curriculum topic: Maternity and Reproductive Health.

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